POS0895 THE ROLE OF SURGERY IN THE ESOPHAGEAL INVOLVEMENT IN SYSTEMIC SCLEROSIS: A SYSTEMATIC LITERATURE REVIEW
Authors: P. Matucci Cerinic, A. Akpabio, M. Hughes, J. Schoones, G. Terrosu, A. Martino, M. Vecchiato, R. Petri, M. Matucci-Cerinic, A. Alunno
Journal: Annals of the Rheumatic Diseases (2022)

Background Among gastrointestinal (GI) manifestations in Systemic Sclerosis (SSc) one of the predominant and challenging problems is gastroesophageal reflux disease (GERD), which occurs in ~75% of patients. Although proton pump inhibitors are useful, they are ineffective in 40% of cases with chronic use at high doses, against the background of long-term risks (e.g., cardiovascular disease and infections) which have been identified in the general population. Surgery might be an option following failure of medical therapy but currently, there is no consensus regarding the optimal surgical procedure for refractory GERD in SSc. Objectives To evaluate, among the surgical approaches to GERD, the feasibility of fundoplication (FP) with regards to its safety, efficacy, indications, and timing. Methods Four research questions based on the PICO framework were developed to guide the systematic literature review that was conducted up to 22 December 2021. The search and performed across different databases including PubMed, MEDLINE (OVID), EMBASE, Cochrane Library, Web of Science, Google Scholar, Emcare and Academic Search Premier. References were independently screened by two reviewers (PMC and AA) who also independently assessed the full text of eligible articles, and extracted data. Due to heterogeneity of retrieved studies, narrative summaries are used to present the data. Results The search yielded 916 papers of which 30 were eligible for full text review. In these studies, out of 2919 clinically heterogeneous patients, 348 SSc patients were identified (mostly female, mean age 52.7 years). Out of these 348, only 257 underwent anti-reflux surgical procedure and were included in the analysis. Most of the studies were conducted in surgical settings and relevant rheumatological data were largely missing. Refractory GERD symptoms, were the commonest indication for surgery, with post-operative dysphagia being the most frequent complication. In 18 studies, FP was effective, whereas 4 studies had equivocal findings and in 5 a lack of efficacy was reported. The Collis-Nissen FP was the most popular procedure overall as well as in earlier studies, followed by Nissen FP, and Dor FP in relatively more recent studies, reflecting the change in surgical strategy over time. The data extracted shows also an acceptable rate of mortality and morbidity related to surgery, and heterogeneous outcome measures were used hampering any comparison of the studies (Table 1). Due to the heterogeneity of the data, it was not possible to separate the mortality and morbidity rate of SSc patients from the rest of the population. Table 1. GERD ASSESSMENT AND SURGICAL OUTCOMES Domain assessed/outcome Instrument/Measurement N° of studies Reflux severity Dysphagia: 20 Number of antireflux medications: 10 High dose PPI: 9 pH monitoring (pre-procedure): 11 Oesophagitis/Barret 4 Reflux improvement (post-procedure) Symptom resolution/reduction 24 pH monitoring 12 Repeat EGDS 8 N° of patients N° of surgical procedures Tot SSc 257 Collis-Nissen FP 54 Nissen FP 39 Dor FP 37 Collis-Belsey FP 20 Toupet FP 18 RYGB 23 Others 30 Undefined 36 Post-operative surgical complications 73 (2,5%)* Mortality (n° deaths) 8 (0,27%)* *rate in total population (2919) Conclusion Our SLR has highlighted that the surgical management of GERD in SSc patients is still highly challenging since the available evidence is scarce and of poor quality. Among the surgical approaches to the problem of GERD, overall FP seems a safe and effective procedure in SSc. Transient post-operative dysphagia was noted in many studies, particularly related with the posterior FP. In the future, it will be necessary to develop minimal requirement to conduct surgical studies in SSc as well as to design studies aimed at defining the clinical criteria for referral to surgery. Indeed, the right timing for surgery and the best surgical procedure in SSc still remains an unmet need. Disclosure of Interests None declared